It is unclear whether the use of clinical prediction rules is sufficient to rule out infective endocarditis (IE) in patients with
bacteremia (SAB) without an echocardiogram evaluation, either ...transthoracic (TTE) and/or transesophageal (TEE). Our primary purpose was to test the usefulness of PREDICT, POSITIVE, and VIRSTA scores to rule out IE without echocardiography. Our secondary purpose was to evaluate whether not performing an echocardiogram evaluation is associated with higher mortality.
We conducted a unicentric retrospective cohort including all patients with a first SAB episode from January 2015 to December 2020. IE was defined according to modified Duke criteria. We predefined threshold cutoff points to consider that IE was ruled out by means of the mentioned scores. To assess 30-day mortality, we used a multivariable regression model considering performing an echocardiogram as covariate.
Out of 404 patients, IE was diagnosed in 50 (12.4%). Prevalence of IE within patients with negative PREDICT, POSITIVE, and VIRSTA scores was: 3.6% (95% CI 0.1-6.9%), 4.9% (95% CI 2.2-7.7%), and 2.2% (95% CI 0.2-4.3%), respectively. Patients with negative VIRSTA and negative TTE had an IE prevalence of 0.9% (95% CI 0-2.8%). Performing an echocardiogram was independently associated with lower 30-day mortality (OR 0.24 95% CI 0.10-0.54,
= 0.001).
PREDICT and POSITIVE scores were not sufficient to rule out IE without TEE. In patients with negative VIRSTA score, it was doubtful if IE could be discarded with a negative TTE. Not performing an echocardiogram was associated with worse outcomes, which might be related to presence of occult IE. Further studies are needed to assess the usefulness of clinical prediction rules in avoiding echocardiographic evaluation in SAB patients.
We aimed to evaluate the clinical outcome of Systemic Autoimmune Diseases (SADs) patients hospitalized with COVID-19 in Spain, before the introduction of SARS-CoV-2 vaccines. A nationwide, ...retrospective and observational analysis of the patients admitted during 2020, based on the ICD10 codes in the National Registry of Hospital Discharges, was performed. Among 117,694 patients, only 892 (0.8%) presented any type of SAD before COVID-19-related admission: Sjogren’s Syndrome constituted 25%, Systemic Vasculitides 21%, Systemic Lupus Erythematosus 19%, Sarcoidosis 17%, Systemic Sclerosis 11%, Mixed and Undifferentiated Connective Tissue Disease 4%, Behçet’s Disease 4% and Inflammatory Myopathies 2%. The in-hospital mortality rate was higher in SAD individuals (20% vs. 16%, p < 0.001). After adjustment by baseline conditions, SADs were not associated with a higher mortality risk (OR = 0.93, 95% CI 0.78−1.11). Mortality in the SADs patients was determined by age (OR = 1.05, 95% CI 1.04−1.07), heart failure (OR = 1.67, 95% CI 1.10−2.49), chronic kidney disease (OR = 1.29, 95% CI 1.05−1.59) and liver disease (OR = 1.97, 95% CI 1.13−3.44). In conclusion, the higher COVID-19 mortality rate seen in SADs patients hospitalized in Spain in 2020 was related to the higher burden of comorbidities, secondary to direct organ damage and sequelae of their condition. Whilst further studies should evaluate the impact of baseline immunosuppression on COVID-19 outcomes in this population, efforts should be focused on the optimal management of SAD to minimize the impact of the organ damage that has been shown to determine COVID-19 prognosis.
We aimed to analyse the efficacy and safety of oral sequential therapy (OST) in uncomplicated Staphylococcus aureus bacteraemia (SAB).
Single-centre observational cohort at a tertiary hospital in ...Spain, including all patients with the first SAB episode from January 2015 to December 2020. We excluded patients with complicated SAB and those who died during the first week. Patients were classified into the OST group (patients who received oral therapy after initial intravenous antibiotic therapy IVT), and IVT group (patients who received exclusively IVT). We performed a propensity-score matching to balance baseline differences. The primary composite endpoint was 90-day mortality or microbiological failure. Secondary endpoints included 90-day SAB relapse.
Out of 407 SAB first episodes, 230 (56.5%) were included. Of these, 112 (n = 48.7%) received OST and 118 (51.3%) IVT exclusively. Transition to oral therapy was performed after 7 days (interquartile range, 4–11).
The primary endpoint occurred in 10.7% (11/112) in OST vs. 30.5% (36/118) in IVT (p < 0.001). SAB relapses occurred in 3.6% (4/112) vs. 1.7% (2/118) (p 0.436). None of the deaths in OST were related to SAB or its complications.
After propensity-score matching, the primary endpoint was not more frequent in the OST group (relative risk, 0.42; 95% CI, 0.22–0.79). Ninety-day relapses occurred similarly in both groups (relative risk, 1.35; 95% CI, 0.75–2.39).
After an initial intravenous antibiotic, patients with uncomplicated SAB can safely be switched to oral antibiotics without apparent adverse outcomes. This strategy could save costs and complications of prolonged hospital stays. Prospective randomized studies are needed.
Introduction
SARS-CoV-2 pneumonia is often associated with hyper-inflammation. The cytokine-storm-like is one of the targets of current therapies for coronavirus disease 2019 (COVID-19). High ...Interleukin-6 (IL6) blood levels have been identified in severe COVID-19 disease, but there are still uncertainties regarding the actual role of anti-IL6 antagonists in COVID-19 management. Our hypothesis was that the use of sarilumab plus corticosteroids at an early stage of the hyper-inflammatory syndrome would be beneficial and prevent progression to acute respiratory distress syndrome (ARDS).
Methods
We randomly assigned (in a 1:1 ratio) COVID-19 pneumonia hospitalized patients under standard oxygen therapy and laboratory evidence of hyper-inflammation to receive sarilumab plus usual care (experimental group) or usual care alone (control group). Corticosteroids were given to all patients at a 1 mg/kg/day of methylprednisolone for at least 3 days. The primary outcome was the proportion of patients progressing to severe respiratory failure (defined as a score in the Brescia-COVID19 scale ≥ 3) up to day 15.
Results
A total of 201 patients underwent randomization: 99 patients in the sarilumab group and 102 patients in the control group. The rate of patients progressing to severe respiratory failure (Brescia-COVID scale score ≥ 3) up to day 15 was 16.16% in the Sarilumab group versus 15.69% in the control group (RR 1.03; 95% CI 0.48–2.20). No relevant safety issues were identified.
Conclusions
In hospitalized patients with Covid-19 pneumonia, who were under standard oxygen therapy and who presented analytical inflammatory parameters, an early therapeutic intervention with sarilumab plus standard of care (including corticosteroids) was not shown to be more effective than current standard of care alone. The study was registered at EudraCT with number: 2020-002037-15.
Evidence to support the use of steroids in coronavirus disease 2019 (COVID-19) pneumonia is lacking. We aim to determine the impact of steroid use for COVID-19 pneumonia on hospital mortality. We ...performed a single-center retrospective cohort study in a university hospital in Madrid, Spain, during March of 2020. To determine the role of steroids in in-hospital mortality, patients admitted with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia and treated with steroids were compared to patients not treated with steroids, and we adjusted with a propensity score for patients on steroid treatment. Survival times were compared using the log rank test. Different steroid regimens were compared and adjusted with a second propensity score. During the study period, 463 out of 848 hospitalized patients with COVID-19 pneumonia fulfilled inclusion criteria. Among them, 396 (46.7%) patients were treated with steroids and 67 patients were not. Global mortality was 15.1%. The median time to steroid treatment from symptom onset was 10 days (interquartile range IQR, 8 to 13 days). In-hospital mortality was lower in patients treated with steroids than in controls (13.9% 55/396 versus 23.9% 16/67; hazard ratio HR, 0.51 95% confidence interval, 0.27 to 0.96;
= 0.044). Steroid treatment reduced mortality by 41.8% relative to the mortality with no steroid treatment (relative risk reduction, 0.42 95% confidence interval, 0.048 to 0.65). Initial treatment with 1 mg/kg of body weight/day of methylprednisolone versus steroid pulses was not associated with in-hospital mortality (13.5% 42/310 versus 15.1% 13/86; odds ratio OR, 0.880 95% confidence interval, 0.449 to 1.726;
= 0.710). Our results show that the survival of patients with SARS-CoV-2 pneumonia is higher in patients treated with glucocorticoids than in those not treated. Rates of in-hospital mortality were not different between initial regimens of 1 mg/kg/day of methylprednisolone and glucocorticoid pulses.
Suicide is an international health concern with immeasurable impact from the perspective of human and social suffering. Prior suicide attempts, anxious and depressive symptoms, and relatively lower ...health-related quality of life (HRQoL) are among the most replicated risk factors for suicide. Our goal was to visualize the distribution of these features and their interconnections with use of a network analysis approach in individuals who recently attempted suicide.
Individuals with a recent suicide attempt were recruited from nine University Hospitals across Spain as part of the SURVIVE cohort study. Anxious and depressive symptoms, and perceived HRQoL were included in the network analysis. Network structures were estimated with the EBICglasso model. Centrality measures and bridge symptoms connecting communities were explored. Subnetworks comparing younger and older individuals, and women and men were analyzed.
A total of 1106 individuals with a recent suicide attempt were included. Depressed mood was the symptom with the greatest influence in the overall network, followed by anxiety symptoms such as feeling nervous, worrying, restless, and having difficulties to relax. Perceived general health was associated with increased suicidal ideation in the whole sample. Older people showed a specific connection between perceived general health and depressed mood.
The cross-sectional design does not allow determination of established causality.
Depressed mood was the core network's symptom and, therefore, an important target in the management and prevention of suicide. HRQoL had more influence on the network of older populations, in which it should be a primary focus.
•Identifying risk factors for suicide is crucial for developing prevention programs.•Network analysis allows studying interrelations of symptoms in suicidal behaviors.•Depressed mood is the core symptom in individuals who recently attempted suicide.
El implante valvular aórtico transcatéter (TAVI) ha mostrado resultados excelentes, constituyendo una alternativa terapéutica a la sustitución valvular aórtica para pacientes de riesgo quirúrgico ...alto o excesivo. Sin embargo, no existe un claro consenso sobre los beneficios del TAVI en pacientes con riesgo quirúrgico intermedio. Realizamos una revisión sistemática de la literatura y el consiguiente metaanálisis considerando resultados periprocedimiento y en el seguimiento máximo disponible.
Se realizó una búsqueda bibliográfica combinando 3 grupos de palabras clave: «TAVR/TAVI/transcatheter aortic valve implantation/transcatheter aortic valve replacement» AND «intermediate risk» AND «aortic valve replacement/AVR/surgery». Fueron considerados los trabajos publicados en los últimos 6 años.
Fueron seleccionados 21 trabajos: 4 estudios prospectivos aleatorizados y 17 estudios observacionales, 13 de ellos ajustados por análisis de propensiones. No existieron diferencias significativas en la mortalidad (RR=1; IC95%: 0,99-1,02) o incidencia de accidente cerebrovascular (RR=0,96; IC95%: 0,77-1,20) en el seguimiento máximo (1-3 años). La lesión vascular (accidente cerebrovascular) grave fue significativamente mayor en el grupo TAVI (RR=4,39; IC95%: 2,17-8,91), así como la necesidad de implante de marcapasos permanente (RR=2,96; IC95%: 2-4,36) y la incidencia de fuga paravalvular significativa (≥2+; RR=6,83; IC95%: 4,64-10,05). Tanto la incidencia de fibrilación auricular (RR=0,39; IC95%: 0,25-0,61) como de fallo renal (RR=0,45; IC95%: 0,28-0,72) fueron superiores en el grupo quirúrgico.
Tras comparar TAVI frente a la sustitución valvular aórtica en pacientes con riesgo quirúrgico intermedio mediante metaanálisis, no se han identificado diferencias significativas en términos de mortalidad o accidente cerebrovascular a lo largo del seguimiento. Sin embargo, el diferente perfil de complicaciones de cada una de las técnicas debería guiar la selección de pacientes realizada por el Heart-Team para reducir la morbilidad posprocedimiento.
Transcatheter aortic valve implantation (TAVI) has shown excellent results, and is a therapeutic alternative to aortic valve replacement for high or excessive surgical risk patients. However, there is no clear consensus about the benefits of TAVI for patients with intermediate surgical risk. A systematic review of literature and subsequent meta-analysis was carried out considering outcomes after the procedure and during the maximum available follow-up.
A systematic review of literature was performed, combining three clusters of Keywords: “TAVR/TAVI/transcatheter aortic valve implantation/transcatheter aortic valve replacement “AND “intermediate risk” AND “aortic valve replacement/AVR/surgery”. Studies published in the last 6 years were considered for analysis.
A total of 21 studies were included in the analysis, of which 4 were randomised controlled trials and 17 were observation studies, with 13 of them being propensity-score adjusted. No differences were found in terms of mortality (RR=1.00, 95% CI: 0.99-1.02) or incidence of cerebrovascular accident (RR=0.96, 95% CI: 0.77-1.20) during the maximum follow-up (1-3 years). A major vascular lesion (cerebrovascular accident) (RR=4.39, 95% CI: 2.17-8.91), need of permanent pacemaker implantation (RR=2.96, 95% CI: 2.00-4.36), and residual significant paravalvular leak (≥2+; RR=6.83, 95% CI: 4.64-10.05) were significantly higher in TAVI group. The incidence of atrial fibrillation (RR=0.39, 95% CI: 0.25-0.61) and kidney failure (RR=0,45, 95% CI: 0.28-0.72) were higher in the surgical group.
After comparing TAVI and aortic valve replacement in patients with intermediate surgical risk using meta-analysis, no significatant differences were identified in terms of mortality or cerebrovascular accident during follow-up. However, the different profile of complications of each technique should guide patient selection by the Heart-Team in order to reduce post-procedural morbidity.
Suicide attempts are an important predictor of completed suicide and may differ in terms of severity of medical consequences or medical lethality. There is little evidence on serious suicide attempt ...(SSA) and very few studies have compared SSA with non-SSA.
The aim of this multisite, coordinated, cohort study was to analyze the role of clinical variables and the sociodemographic and psychological risk factors of SSA.
In this multisite, coordinated, cohort study, 684 participants (222 for the mild suicide attempt group, 371 for the moderate suicide attempt group and 91 for the SSA group) were included in the study. Ordinal regression models were performed to analyze the predictor variables of SSA.
Early physical abuse (OR=1.231) and impulsivity (OR=1.036) were predictors of SSA, while depressive symptoms were associated with a lower risk of SSA.
Environmental and psychological factors as physical abuse and impulsivity are related with severe suicide severity. These findings will help to develop strategies to prevent suicide and may be considered for the treatment and management of suicide.
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